Customer Service Manager
Resume:
Mary H. Fischer
Aurora, CO *****
********@*****.***
SUMMARY
** ***** ********** ********** ** health insurance operations. Experience
includes managing medical and dental claims teams, quality improvement
teams consisting of claims and call auditors, training and development
teams, overpayment recovery teams, cost management teams, claims adjustment
teams, medical management teams, and customer service teams. Experienced in
fully insured, self-funded, CHP +, Medicaid, and Medicare administration.
EDUCATION
University of Colorado, Boulder, Colorado
Bachelor of Arts-Molecular Cellular Development Biology, June 1989
Denver Paralegal Institute, Denver, Colorado
Paralegal Degree, October 1989
EMPLOYMENT
Colorado Access, Denver Colorado
Sr. Manager of Claims and Appeals 2010-current
. Accountable for the execution of claim and appeals operations, ensuring
claim management accuracy and timeliness, exceptional service delivery,
and all associated people management responsibilities.
. Active in provider partnerships, provider relations, and quality
management programs, performance management/improvement, complaints and
appeals, and reporting.
. Manage Colorado Access auditing staff and monitor accuracy to ensure that
all Service Level Agreements are met.
. Ensure compliance with all regulations, laws, guidelines and service
standards for all Colorado Access lines of business
ACS, Inc (Fiscal Agent for Colorado Medicaid), Denver, CO
Supervisor of Provider Services Call Center, 2009-2010
. Manage call center team of 12 call center agents to meet SLAs for
Colorado Medicaid, including ASA, Abandonment rates, and call quality
. Handle all escalated issues which include provider enrollment, claims
adjudication, prior authorizations, and provider education
. Develop and deliver new hire training
. Meet weekly with Health Care Policy & Finance State management to ensure
ACS is delivering accurate and current State Medicaid requirements
Great-West HealthCare, Fort Scott, Kansas
Director of Quality Improvement, 2005-2008
. Manage 7 teams, 62 individuals. Teams include claims and call auditors,
trainers, claims adjusters, overpayment specialists, benefit
coordinators.
. Improved claims financial accuracy from 95% to exceeding company metric
of 99% in 6 months. Goal had not been met in 2 years.
. Decreased adjustment inventory from 15,483 and 13.7 days on hand to 1,170
and 1.9 days on hand in 12 months by creating more efficient workflows
. Perform on-going root-cause analysis for continued quality improvement,
operational efficiency, and training needs
CNIC Health Solutions, Denver, Colorado
Manager of Medical and Dental Customer Service and Claims Teams, 2003-2004
. Managed two teams of 21 claims examiners and customer service
representatives
. Decreased ASA from 90 seconds to below company metric of 20 seconds, and
increased claim production from 3 per hour to 12
. Managed claim inventory to below company metric of 95% processed in 10
business days or less
. Researched and responded to all member and provider appeals
CIGNA Health Care (contact work), Denver, Colorado
Claims Financial Analyst, 2002-2003
. Conducted internal audit of system claim payment against system provider
contract reimbursement data
. Performed root-cause analysis for corrective action to deviations from
contract implementation and claims adjudication
Kaiser Permanente, Denver, Colorado
Manager of Quality & Resource Management, 2000-2002
. Managed four teams of 22 RNs. Teams were Inpatient Review, Case
Management, Referral, Transplant Coordinators, and Patient Transfer
nurses
. Implemented cost saving initiative which resulted in over $10 million in
out of network hospital related savings
. Successfully completed NCQA accreditation review and received 'Excellent'
in all lines of business, including HEDIS measures and CAHPS scores
. Developed auto-authorization list and claims adjudication process to
increase claim production, and increase workflow efficiency
. Created departmental standards, manuals, training, policies, and
procedures to maximize work efficiency, consistency, and to maintain
quality
Community Health Plan of the Rockies, Denver, Colorado
Director of Claims and Medical Management, 1997-2000
. Managed department of 25 RNs, LPNs, and Pharmacy Technicians in call
center environment and 25 claims examiners
. Teams performed inpatient and outpatient review in accordance with plan
provisions, and InterQual, and Milliman and Robertson criteria
. Trained staff in utilization management, plan designs, claim processing
system, eligibility, claim adjudication, and national criteria
. Successfully prepared for and responded to Colorado State Medicaid
Contract Audit, including the required HEDIS measures and CAHPS scores
MetLife/United Healthcare, Denver, Colorado
Manager of Medical Claims and Customer Service, 1991-1996
. Supervised team of 35 claims examiners and customer service
representatives
. Tracked and responded to member and provider appeals to ensure all
regulatory requirements were met, as well as, trended for improvement
opportunities
. Developed training materials and performed training for new employees for
claims processing, call center, and claim adjustments
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